Healthcare Provider Details

I. General information

NPI: 1336718089
Provider Name (Legal Business Name): LA B&B ENTERPRISE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2021
Last Update Date: 03/19/2025
Certification Date: 03/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3156 CALGARY ST
MELBOURNE FL
32935-4639
US

IV. Provider business mailing address

1007 N FEDERAL HWY # 381
FORT LAUDERDALE FL
33304-1422
US

V. Phone/Fax

Practice location:
  • Phone: 321-374-4785
  • Fax: 321-732-4942
Mailing address:
  • Phone: 757-392-9800
  • Fax: 888-818-1230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: LISA A BAKER
Title or Position: PRESIDENT
Credential: AUTONOMOUS PROVIDER
Phone: 321-374-4785